5. Are you currently experiencing overwhelming sadness, grief, or depression? *

YesNo

If yes, for approximately how long?

6. Are you currently experiencing anxiety, panic attacks, or have any phobias? *

YesNo

If yes, when did you begin experiencing this?

7. Are you currently experiencing any chronic pain? *

YesNo

If yes, please describe:

8. Do you drink alcohol more than once a week? *

9. How often do you engage recreational drug use? *

NeverDailyWeeklyMonthly

10. Are you currently in a romantic relationship? *

NoYesInfrequentlyNever

If yes, for how long?

On a scale of 1-10, how would you rate your relationship?

11. What significant life changes or stressful events have you experienced recently: *

FAMILY MENTAL HEALTH HISTORY: In the section below, identify if there is a family history of any of the following. If yes, please indicate the family member’s relationship to you in the space provided (father, grandmother, uncle, etc.).

List Family Member

Alcohol/Substance Abuse:

YesNo

Anxiety:

YesNo

Depression:

YesNo

Domestic Violence:

YesNo

Eating Disorders:

YesNo

Obesity:

YesNo

Obsessive Compulsive Behavior:

YesNo

Schizophrenia:

YesNo

Suicide Attempts:

YesNo

RISK ASSESTMENT:

Any risk factors present? *

YesNo

If yes, specify current risk factors:

Potential for violence: *

YesNo

Hostile/ Abusive behavior: *

YesNo

Major Depression: *

YesNo

Suicidal Ideation/Intent/Plan: *

YesNo

PAST RISK FACTORS

Suicide Attempts: *

YesNo

Violent Behavior: *

YesNo

Inpatient Hospitalization: *

YesNo

Hostile/Abusive behavior: *

YesNo

Major Depression: *

YesNo

Suicidal Ideation/Intent/Plan: *

YesNo

ADDITIONAL INFORMATION:

1. Are you currently employed? *

YesNo

If yes, what is your current employment situation?

Do you enjoy your work? Is there anything stressful about your current work? *